Geriatric Mental Health Disaster and Emergency Preparedness

Chapter 10 Psychosocial and Pharmacological Interventions 191
the short-term use of a benzodiazepine with a short half-life, such as lorazepam,
in the client with overwhelming fear, dread, and panic symptoms
that are not responsive to psychological support. The choice of medication,
as previously noted, should be based on the degrees of distress, the
current and chronic medical problems of the client, the total amount of
medications they are taking, and other risk factors for falls, such as sedation
and confusion. Sedatives such as barbiturates, meprobamate, and
diazepam should be avoided due to their accumulation in the body.
The client with a prior history of PTSD who was asymptomatic but
then experienced another trauma is at risk for a recurrence. If warranted,
a trial of a selective serotonin reuptake inhibitor (SSRI), the pharmacologic
treatment of choice for anxiety and panic, should be initiated, which
will also be effective in improving symptoms of depression. SSRIs are
considered the first-line pharmacological treatment for PTSD. However,
even when treated with this class of drugs, response rates rarely exceed
60% and less than 20–30% of patients achieve full remission (Schoenfeld,
Marmar, & Neylan, 2004). Agents such as citalopram and escitalopram
have a relative benign side effect profile in the older client and can be initiated
at an initial dose of 5–10 mg per day. Sertraline in younger adults
was effective in the PTSD clusters of avoidance and arousal but not
in symptoms of re-experiencing the events (Brady, Pearlstein, & Asnis,
2000).
At this time, there are six SSRIs currently available on the world market:
sertraline, paroxetine, fluoxetine, fluvoxamine, citalopram, and escitalopram.
Although only the first two have FDA approval for PTSD
treatment, the others are also commonly used for this purpose. Although
double-blind trials do not exist, evidence from open trials suggests that
fluvoxamine and escitalopram may also be helpful for PTSD (Davidson,
Weisler, Malik, & Tupler, 1998; Robert, Hamner, Ulmer, Lorberbaum, &
Durkalski, 2006). Other agents for mitigating depression in older persons,
including SSRI and serotonin-norepinephrine reuptake inhibitor (SNRI)
medications, are better tolerated in the older population than tricyclic
antidepressants and cause fewer cardiovascular side effects. Trazodone
has some benefit for nighttime calming and sedation and is used widely
as an adjunctive treatment for depression-associated insomnia.
Nightmares and chronic insomnia can be extremely debilitating.
Prazosin, an alpha-1 adrenergic blocking agent, has been used with some
success for this purpose and appears to improve these symptoms without
causing significant orthostatic hypotension (Peskind, Bonner, Hoff, &
Raskind, 2003). Hypnotics are commonly used in the treatment of